Constantly Connected: What Healthcare Providers Need to Know About Vicarious Trauma in an Evolving Digitally Connected Global Community

Abstract

Easy access to streaming news and sensational headlines has transformed society’s exposure to traumatic narratives. From personal stories on social media platforms to news articles about violence in communities, patients and their caregivers may not recognize their exposure as traumatic nor recognize their psychological sequalae as unhealthy. In addition, youth with trauma-related mental health symptoms are not consistently identified in pediatric primary care clinics. Due to the increase in proximity to traumatic stories, healthcare providers working with youth require additional skills designed to engage patients and families in conversations about exposure to violence via technology and symptoms of vicarious trauma. This article aims to summarize current understanding of vicarious trauma via technology, the impact of vicarious trauma on youth, and provide best practices to improve providers’ ability to disseminate evidence-based guidance.

The Case for Vicarious Trauma

This week I met with a friend, who was beside herself after learning a friend’s teenage son died by suicide the night before. She had known this teenager since he was five years old. He was best friends with her grandson, and they had grown up together. This teen appeared to have everything going for him. He had a loving two-parent, financially-sufficient, family home, an active and stable social life, and a safe academic atmosphere where he received good grades.

What went wrong? How did no one know he was suffering? His family shared that, although he openly talked about social worries and concerns, these were common discussions among his peers. There had been a mass shooting at a sports rally killing one bystander, injuring many, and traumatizing hundreds, as well as current domestic and foreign political divisiveness, but he wasn’t directly connected to those situations. Or was he?

These types of stressful, even traumatic, events are not new in the world. Could this teen have felt more connected and closer to these events due to technology and social media than what many of us are used to when hearing about social, political, economic unrest and violence? Historically, connection to community and world unrest looked and felt different for many. Families would huddle together to watch the evening news, balking at the awful scenes on television, even that of war, riots, and terrorism on both foreign and local soil. They would talk as a family about the scary, disturbing events and their ways to maintain safety. Then they might say some prayers and turn off the television. All went to bed and their brains processed and reprocessed the news, eventually allowing their stress response systems to return to baseline. They had a good night’s sleep and awoke the next day to tackle new things, both good and bad.

This does not seem to be the case for young people today. They are seeing horrific events, not only on television during the news hours, but also watching repetitively on the 24-hour news cycle. They can read opinions via blogs on their phones and never miss the late-breaking updates. They can view live updates from individuals in war zones or from within schools during an active shooter event. What used to be far away horrors, buffered by adult monitoring and scheduled depictions of news, are now impacting our children’s day-to-day lives more and more.

Trauma Defined

The diagnosis of Post-Traumatic Stress Disorder (PTSD) was first included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in its third edition,¹ published in 1980. With its inclusion, there was an acknowledgement that traumatic events can impact human experience, mental health challenges can result from experiences outside of oneself (i.e., not just a character flaw), and that traumatic events impact the brain and body differently than “normal stressors.” In the current edition of the DSM (DSM-5), PTSD as a diagnosis is defined by the following:² A) Exposure to actual or threatened death, serious injury, or sexual violence via directly experiencing the event, witnessing in person the event as it occurred to others, learning that the event occurred to a close family member or close friend, or experiencing repeated or extreme exposure to aversive details of the event (e.g., first responders and emergency response professionals); B) Presence of at least one intrusion symptom associated with the event (e.g., intrusive memories, recurrent dreams/nightmares, dissociative re-experiencing); C) Presence of at least one form of avoidance toward stimuli associated with the event (e.g., avoiding memories of event, avoiding external reminders of event); D) Presence of at least two changes in cognition and mood associated with the event (e.g., difficulties remembering parts of the event, negative cognitive beliefs, blaming of self for the event, feeling detached from relationships); E) Presence of at least two changes in arousal/reactivity associated with the event (e.g., irritability, self-destructive behavior, hypervigilance); F) Duration of disturbances is more than one month; G) Disturbances causes significant distress or impairment; and H) Disturbances not attributable to other conditions or substance use/abuse.

Since the 1990s, there has been an increased awareness that the DSM definition of traumatic events and associated trauma-related symptoms and diagnoses may not properly represent alternate forms of trauma, such as instances of prolonged, repeated interpersonal violence, vicarious trauma (i.e., that experienced through watching/hearing of traumatic events on electronic devices/platforms), or complex developmental trauma, which significantly impact functioning in similar and different ways than that demonstrated in “traditional PTSD.”³

Within the DSM-5, there is a specific note that exposure to a traumatic event cannot include exposure via electronic media, television, movies, or pictures, unless the exposure is work related.² In effect, what this means, is that an individual presenting with trauma-related symptoms in response to watching non-stop coverage of a recent mass shooting would not meet criteria, may not receive appropriate support and intervention, and may not even be identified as having trauma-related symptoms due to lack of screening. This issue is especially salient for youth due to differences in presentation of trauma-related symptoms in younger populations, developmental shifts in cognitive and emotional processing, and social media use.

Technology Advances in Entertainment, Connections, and Media

Advances in and access to technology have significantly changed our lives in the past 25 years. In 2000, only 50% of households in the US had one or more computers, and fewer than 7% of individuals around the world were online.^4–5 In 2011, 35% of the US population had a mobile phone. Today, 98% own a cellphone with over 90% owning a smartphone. Most of the world’s population now has access to the internet. There are more cellphones in existence than there are people in the world. ^4–6

With expansions in access to technology, choice on where and how to connect with others has also increased. Social media was first on the horizon in early 2000s with less than one million connected to MySpace.⁴ Today, Facebook has nearly three billion active users each month.⁷ There are numerous social media platforms from which to choose and many teens report using social media daily.⁶ Dixon reports that the average internet user is spending 2.5 hours per day on social media, which is up from 40 minutes per day nine years ago.⁷ Online connections have shown benefits for teens, including increased felt social connection with others who share similar identities and interests.⁸ However, online connections can also mean increased awareness of events negatively impacting friends, loved ones, and even complete strangers, causing increased emotional distress and fear.⁹

Technological advances have also expanded access and choice of news. A 2015 Pew Research study showed that nearly 70% of the those in the US who access internet via their smartphones, follow “breaking news” on their phone and report forwarding pictures and videos depicting news events.⁹ For our youth, the Pew Research Center found that almost half do not trust national news sources.¹⁰ Studies show that over half of teens aged 14–18 obtain their news from social media rather than traditional news media. In fact, although television, print, and radio continue to be the preferred news sources for older groups, Instagram and TikTok are the most popular source for news among younger people.^12–13 Algorithms in social media applications are designed to increase frequency of content users engage with. When there is a tragic news story that a teen has investigated, it is likely they will be bombarded with similar stressful and traumatic content, potentially without the tools or resources to properly cope and process information.¹⁴

Social Media and Trauma Exposure

Researchers have made a clear case that access to social media can be both helpful and dangerous for teens. Dangers include decreased self-esteem/body image, and increased risk of bullying, emotional problems, and sexual violence.^15–16 Adolescents are at high risk for these effects due to their less mature abilities to manage peer pressure and emotional regulation.¹⁶

In addition, researchers have examined links between trauma exposure and emergence of trauma-related symptoms. Related to large scale disasters, a person’s level of proximity to traumatic events and frequency of exposure to news coverage is relevant to their risk for developing trauma-related symptoms.¹⁷ Though it is common to seek information following a large-scale disaster for safety purposes and to mitigate growing anxiety, studies show that viewing images with humans in life-threatening circumstances causes high emotional and physical reactivity.¹⁸ Examples of these types of events in just these past few years have included the invasion of Ukraine, a massacre at an Israeli music festival with retaliation leading to tens of thousands of harmed children and families in Israel and Palestinian territory, mass shootings at public places, natural disasters across the globe, and severe child maltreatment. While television news has been studied to determine the effects of graphic news content on individuals, we have only limited research regarding the impact of news gathering via social media on youth and adults.¹⁰

Sequalae of Vicarious Trauma

Vicarious (or secondhand) trauma is conceptualized as a change or threat to one’s beliefs, assumptions, and expectations about the self and/or the world that occurs due to exposure to stories, evidence of or disruption in one’s safety, trust, esteem, independence, and frame of reference.¹⁸ In essence, it is a fundamental shifting of what we know or believe to be true about the world, that distresses us and creates fear, dread, and the symptoms of traumatic experience despite the trauma being non-personal.

This experience of vicarious traumatization has been observed in individuals working first-hand with eyewitness news media covering traumatic events,¹⁹ citizens viewing COVID-19 pandemic media or bombings,²⁰ and in communities exposed to systemic or structural violence.²¹ At this time, there are limited studies on the effects of media consumption and occurrence of vicarious trauma in children and adolescents. As reviewed above, we know there is a direct correlation between length of exposure to traumatic narratives, frequency of observation, intensity, and/or proximity to worldview-changing aspects of vicarious exposures to the occurrence of vicarious traumatization in individuals, which we can assume is similar in youth populations. Recognizing the symptoms, early unhealthy sequalae, and functional impairments is crucial in the primary care setting, as early identification and intervention can be invaluable. The symptoms are often very similar to those of PTSD, but do not have a crucial element of threat to self (at least not directly; first criterion). Figley identified three categorical effects including: 1) psychological distress or dysfunction, 2) cognitive shifts, and 3) relational disturbances.^22–23 These categories generally focus on impairment in typical functioning and shifts from baseline for the individual in question.

Behavioral effects can include: nightmares (usually about content or emotionally-related content to that which is observed), intrusive thoughts, disturbing imagery (often intrusive), avoidance of material, sleep disturbance, somatic complaints (stomachaches, headaches, dizziness, fatigue), physiological arousal (increased heart rate, breathing, jitters), disruption to interpersonal relationships, difficulty with school or work, and/or counterintuitive insistence of consuming more related content. Emotional effects can include: anger, sadness, anxiety, numbing, and/or low mood/depression. And finally, cognitive effects can include: change in worldview, paranoia/heightened sense of vulnerability, increase in distrust, increased dependency, sense of helplessness, and/or externalizing of locus of control.

In contrast to adult presentations of PTSD, it is essential to recognize that early trauma-related symptoms in children are often more nuanced. This has been recognized in the DSM-5 with subtypes for children six and younger and is largely recognized in the field as limiting when describing vicarious traumatization or stress. The symptoms listed above may combine, be more intense in one area over another, or be presented more by impairments in role or life than internalized experiences. For example, in children and adolescents, exposure to trauma, particularly in a repeated way, can create a youth who is more insecure in their safety in the world, wary of others, and generally more suspicious.²⁴ Motta highlights that children and adolescents’ experience of trauma often presents as a “pervasive and persistent alteration of one’s self-view and a wary take on their environment,” suggesting that our youth may be forever changed by their experiences of trauma, regardless of intervention. ²⁴

What Can Providers Do?

Universal Screening

Add screening questions to capture social media trauma exposure and negative mental health sequelae. Provide explanation and choice of participation in screening questions to yield more engagement from patients.²⁵ This can be as simple as voicing: “I want to make sure my patients are safe and managing stress as best they can. We know that what young people see on screens, including things in the news or on social media pages, can be scary or disturbing. I’d like to assess your level of screen interaction, and any struggles related to this. You can choose to answer or not.” Then asking: 1) Do you access news media, including social media sites like TikTok? 2) Are there times you feel bad, sad, or scared after viewing news about local, national, or international events? and 3) Have there been times someone has frightened or harmed you through social media (e.g., online bullying) recently or in the past?”

If they screen positive to questions #2 or #3, consider offering a PTSD symptom screener, such as the Adolescent Primary Care Traumatic Stress Screen (APCTSS*) below. ²⁶

In the past month, have you: 1) Had bad dreams about scary experiences or other bad dreams? 2) Had upsetting thoughts, pictures or sounds of scary experiences come into your mind when you didn’t want them to? 3) Tried not to think about or have feelings about scary experiences? 4) Been mad at yourself or someone else for making the scary experiences happen, not doing more to stop it, or to help after? 5) Felt jumpy or easily startled, like when you hear a loud noise or when something surprises you? (*Two or more positive responses on the APCTSS indicate concern for PTSD.)

If risk of PTSD or trauma-related symptomology are identified, there exist a number of evidence-based interventions that reduce trauma responses in youth and families, such as Trauma-Focused Cognitive Behavioral Therapy. Consider referral to a behavioral health clinician who treats PTSD.

Guidance During Times of Crisis in the News

For all patients seen in primary care settings and healthcare settings for youth, it is important to assess and provide education regarding exposure to trauma.^27–28 The following recommendations can be utilized both as prevention and in response to concerns expressed, whether screening is negative or positive.

Safety Check-Ins, Assess Reactions

Exposure to news during times of disaster can exacerbate feelings of hopelessness, anxiety or overwhelm. Assess thoughts of suicide, hurting self or others, or fear of dying. Ask what upsets or worries them about what is going on? How are they coping with their feelings? Validate their concerns when possible. “What is happening is awful. It’s upsetting to see others going through this. Your reactions are understandable.” Fact check if needed. Remind them that social media feeds are not always accurate information. Put into context. When appropriate, clarify they are not directly in harm’s way. Remind caregivers and youth they can call 988 any time if concerns arise.

Empower

Help them focus on what they can control rather than on what they cannot control. Suggest finding ways they can provide positive impacts. Are they able to volunteer for organizations supporting their interests related to the event? The more individuals feel like they can make meaningful contributions to situations, the less likely they will experience negative stress responses.

Maintain Routines

Encourage returning to regular schedules. Structure can reduce perceptions of anxiety and unpredictability.

Limit Exposure

Recommend refraining from watching news 24/7. Turn off news notifications. Turn phone and news off at bedtime to allow stress response to return to baseline. Encourage social media breaks.

Engage Caregivers

Check-in with the caregiver. Do they have the resources they need? Youth take cues from caregivers and other adults around them. Encourage caregivers to model healthy technology use, coping with news, and coping with distress. If caregiver needs to vent or discuss further, suggest they do so with adult friends, family, or therapist rather than with their youth. Encourage healthy family connections and viewing material together with supervision, digestible dialogue, and support offered.

Future Directions

Thus far, much of the research and clinical decision-making processes related to trauma have focused on symptoms following traumatic events directly involving an individual or someone they know. However, there is a growing awareness that our youth and adults are experiencing stress responses to vicarious exposure to local, national, and international events due to current levels of access to information and interaction via electronic devices and social media. The following areas of research would expand our current understanding: the impact of different types of media on vicarious trauma symptoms; feasibility and acceptability of screening for vicarious trauma in medical clinics with patients/families; risk and protective factors for vicarious trauma via electronic means; screening tools to assess for exposure to vicarious trauma and presence of vicarious trauma symptoms; treatment recommendations for vicarious trauma; and effective structural interventions for youth social media use (e.g., phone free zones).